Annals of Coloproctology

Volume 21(1); February 2005

Original Articles

Efficacy of Each Parameter in Clinical Application of Rectoanal Inhibitory Reflex.: Seong, Moo Kyung , Yoo, Young Bum , Park, Byung Ki; J Korean Soc Coloproctol. 2005;21(1):1-5.

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Abstract PDF: PURPOSE
Recently, analytical studies of the various parameters of rectoanal inhibitory reflex were reported and revealed that many of the parameters showed significant differences according to the anal continence function. The standardization of these studies is, however, not yet sufficient enough to apply to use those parameters in reflex test for clinical practice. The aim of this study was to check how the parameters react differently to various degrees of rectal distention and to determine the efficacy of each parameter in clinical applications of rectoanal inhibitory reflex.
METHODS
Thirty-two subjects underwent repeated manometries for rectoanal inhibitory reflex with different volumes (40, 60, 80 cc) of rectal ballooning. Latencies, amplitudes, slopes, durations, and areas under the reflex curves of the reflexes were measured, and the differences among them according to the ballooning volume in each subject were analyzed statistically.
RESULTS
The area under reflex curve, the amplitude, the duration, and the slope did not differ statistically with the ballooning volume (P values were 0.3959, 0.2142, 0.2080, 0.1453, respectively, by repeated measures two way ANOVA). However, the latencies did differ significantly (P=0.0131).
CONCLUSIONS
Most of the parameters except latency were stable against different volumes of rectal ballooning. Among the stable parameters, the area under the reflex curve seemed to be the most useful in clinical applications of rectoanal inhibitory reflex.

Clinicopathologic Features and Clinical Significance of Small and Diminutive Colorectal Polyps.: Lee, Soong , Kim, Seong Ho , Lee, Doo Young , Sun, Jae Hyung , Park, Jin Seok , Park, Ju Sup , Yang, Dae Hyun , Na, Ho Young , Kim, Ky Tai; J Korean Soc Coloproctol. 2005;21(1):6-12.

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Abstract PDF: PURPOSE
Small (6 to 10 mm) and diminutive colon polyps (below 5 mm) are routinely removed at the time of colonoscopy for the prevention of colon cancer. Our aims in this study were to determine clinicopathologic features and frequency of significant synchronous neoplastic lesions of small colon polyps and diminutive colon polyps and to investigate development of colorectal carcinoma via surveillance colonoscopy.
METHODS
We evaluated medical reports of all patients undergoing total colonoscopic examination over a 12-month period. Three hundred thirty nine small colorectal polyps, removed during colonoscopy, have been analyzed. We investigated the result of surveillance colonoscopy, also. Using this database, all adenomas were categorized into two groups: Group I, < or =5 mm diameter (diminutive polyp), Group 2, 6 to 10 mm diameter (small polyp). Significant synchronous adenomas were defined as adenoma over 6 mm diameter, dysplasia or cancer.
RESULTS
The most common age group was the sixth decade. The male-to-female ratio was 2.1 : 1. Of the small colorectal polyps, 180 (53.1%) were adenomatous, 32 (10.0%) were hyperplastic, 119 (34.9%) were chronic nonspecific inflammation, 3 (0.9 %) were lymphoid hyperplasia, and 4 (1.1%) were cancerous. The most frequent sites of these lesions were rectum and sigmoid (60.2%). Recognizable endoscopic features of polyps were redness (35.8%) and nodule (26.3%). The prevalence of advanced proximal synchronous polyps was 20.7% among patients with distal small lesions. And we detected 2 cases (25%) had new small polyps in follow up colonoscopic examination. CONCLUSIONS: All polyps should be removed when encountered during colonoscopy due to the higher prevalence of adenoma among these lesions. Effort to find new polyps via surveillance colonoscopy is needed.

The Role of CD24 in Colonic Adenocarcinoma.: Lee, Seog Ki , Lim, Sung Chul , Kim, Kyung Jong; J Korean Soc Coloproctol. 2005;21(1):13-18.

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Abstract PDF: PURPOSE
CD24 is a small, heavily glycosylated glycosylphosphatidylinositol-linked cell surface protein that is expressed in hematologic malignancies and in a large variety of solid tumors. It appears to function as a ligand of P-selectin, an adhesion molecule that is present in activated platelets and endothelial cells. We aimed to evaluate CD24 protein expression in adenomas and adenocarcinomas of the colon and to correlate it to clinicopathological data.
METHODS
Adenomas and adenocarcinomas of the colon were stained for CD24 immunohistochemically. For statistical analysis, the staining was categorized according to stainability (negative, weakly, moderately, strongly positive) and staining patterns (membranous vs. intracytoplasmic).
RESULTS
The present study clearly demonstrated that CD24 was much more abundantly expressed for adenocarcinomas than for adenomas in the colon (P <0.05). A higher significant association of cytoplasmic CD24 expression was observed with adenocarcinomas of the colon than with adenomas of the colon (P <0.05) and with positive nodal status of the colonic adenocarcinoma than with negative nodal status of the colonic adenocarcinoma (P <0.001).
CONCLUSIONS
The stainability and the staining pattern of CD24 is an important molecular marker for colonic epithelial neoplasms and may help to define malignant transformation and to predict lymph-node metastasis.

Preoperative Chemoradiation Therapy in the Management of Locally Advanced Rectal Cancer.: Kim, Ik Yong , Shin, Dae Geun , Park, Kyung Ran , Sung, Seong Hoon , Chu, Young Keun , Kim, Dae Sung; J Korean Soc Coloproctol. 2005;21(1):19-26.

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Abstract PDF: PURPOSE
Surgery is the standard care in the treatment of rectal cancer. However, after surgery alone, local recurrence and distant metastasis remain high for locally advanced rectal cancer. Preoperative chemoradiation therapy (pre-CRT) has been thought to be effective for increasing resectability and decreasing the rate of local recurrence for locally advanced rectal cancer. This study was designed to assess the efficacy of preoperative concurrent chemoradiation therapy in the management of locally advanced rectal cancer.
METHODS
Between July 1999 and December 2003, 29 patients had locally advanced rectal cancer (uT3/ T4, uN1 by endorectal ultrasonography) or were ineligible to undergo sphincter-preserving surgery. All patients were treated with pre-CRT, followed by surgery in 25 patients. Patients were treated with radiation therapy with a total dose of 45~50.4 Gy to the surgical bed and pelvic lymph- node area for 5.5 weeks. We analyzed the degree of toxicity and the therapeutic resopnse from CRT, the type of surgery, including sphincter-saving procedures, and the mid- term outcome.
RESULTS
Of the 29 patients who received pre-CRT, a radical resection was possible in 25 patients. A low anterior resection and an ultra-low anterior resection- coloanal anastomosis were performed in 13 (52%) and 7 (28%) cases, respectively. Sphincter-preserving surgery was performed in 80% of the patients. The postoperative pathological response rates of CRT were 25% complete remission, 45% partial remission, 30% no response. Postoperative complications and toxicity from CRT were acceptable. The duration of median follow-up was 24 months (9~62 months). Recurrence was seen in 6 cases. Distant recurrence alone was seen in 5 patients (19.2%) and distant and local recurrences were seen in only one patient (4%). The 3-year overall survival rate was 72.4%, and 3-year disease-free survival rate was 59.5%.
CONCLUSION
Our data suggested that preoperative concurrent CRT therapy for locally advanced rectal cancer is safe and tolerable. These data showed a high local control rate and a high 3-year survival rate. Preoperative CRT was an effective modality for sphincter preservation in selected patients who would have required an abdominoperineal resection. Additional studies with larger numbers of patients and long-term follow up are warranted to confirm our results. In addition, more effective chemotherapeutic regimens are needed to decrease distant metastasis.

COX-2 and iNOS Expression and Microvessel Density by Microsatellite Instability in Colorectal Cancer.: Jin, So Young , Kim, Jin Won , Jang, Yong Seog , Kim, Jae Joon , Hong, Sung Ho , Cho, Choo Yon; J Korean Soc Coloproctol. 2005;21(1):27-35.

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We tried to identify the overall incidence of microsatellite instability (MSI) and the utility of mismatch repair (MMR) protein expression in sporadic colorectal cancers in Korean. We also investigate the role of angiogenesis in colorectal cancers by MSI status.
METHODS
A total 85 resected colorectal cancers were submitted for MSI study using PCR methods with 5 markers and immunohistochemistry (IHS) for hMLH1 and hMSH2. Expression of COX-2 and iNOS and microvessel density by IHS were correlated with various clinicopathologic prognostic factors.
RESULTS
Among 85 cases of sporadic colorectal cancers, MSI was observed in 11 cases (12.9%) including 10 MSI-H and 1 MSI-L cases. Patients with MSI (+) showed female prevalence (1.75 : 1), low Dukes stage, mucinous histologic type, and Crohn-like lymphoid reaction than those with MSS. Overall sensitivity of hMLH1 and/or hMSH2 expression was 98.6% and specificity was 72.7%. iNOS expression was significantly correlated with COX-2 expression in tumor cells (P=0.006), however, they were not correlated with MSI status. High microvessel density was correlated with hMLH1 expression (P=0.025), COX-2 expression (P= 0.05), and Crohn-like lymphoid reaction (P=0.041).
CONCLUSIONS
IHS for MMR proteins is a valuable substitute of MSI status and COX-2 related neoangiogenesis is thought to be related to inhibition of microsatellite unstable colorectal cancer progression via decreased microvessel density.

The Significances of EGFR Overexpression in Colorectal Cancer.: Kim, Hyun Ah , Lee, Ryung Ah , Hwang, Dae Yong , Park, Sun Hoo; J Korean Soc Coloproctol. 2005;21(1):36-41.

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Epidermal growth factor receptor (EGFR) is a transmembrane cell surface receptor which has tyrosine kinase activity stimulated upon EGF binding. EGFR was found to be up-regulated in various malignancies. Recently, chimeric monoclonal antibody (C225) to EGFR is under investigation as a targeted therapeutic agent for advanced colorectal cancer. Along with this advance, identification of EGFR expression in colorectal cancer became more important.
METHODS
To investigate the expression of EGFR in colorectal cancer, we carried out the immunohistochemical staining in surgical specimen of 46 consecutive enrolled colorectal cancer patients of Korea Cancer Center Hospital from August, 1998 to June, 1999. The stained slides were read by pathologist and scored as negative or positive. These results were analyzed according to clinical parameters.
RESULTS
Average age was 55 years old (32~73 yr) and sex ratio was 1.56 : 1. The expression rate of EGFR in colorectal cancer was 56.5% (26/46 cases). EGFR expression was not correlated with age, sex, Tie-1, Tie-2 expression, TNM stage, lymphatic invasion, presence of distant metastasis, serum VEGF level. We could not find out staitistical difference of survival according to EGFR expression.
CONCLUSIONS
EGFR overexpression was well characterized by immunochemical staining method, which could be applied easily as a basic pathologic step to decide additional therapy after resection for advanced colorectal cancer.

Differences of Response Rates according to Metastatic Sites after Oxaliplatin, 5- Fluorouracil, and Leucovorin Combination Chemotherapy (FOLFOX 3) in Advanced Colorectal Cancer.: Lee, Seung Hyun , Ahn, Byung Kwon , Baek, Sung Uhn; J Korean Soc Coloproctol. 2005;21(1):42-47.

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Oxaliplatin is a recently developed active agent in colorectal cancer. Clinical observations have demonstrated synergistic effects of oxaliplatin with 5-fluorouracil (5- FU) and leucovorin (LV), even in 5-FU-resistant colorectal cancer. The purpose of this study was to determine response rates according to clinical factors after oxaliplatin, 5-FU and LV combination chemotherapy (FOLFOX 3) in metastatic colorectal cancer.
METHODS
We reviewed 44 patients who had received FOLFOX 3 from Jan. 2000 to Dec. 2002. The combination chemotherapy consisted of oxaliplatin (85 mg/m2 on day 1) as a 2~6 hour infusion followed by continuous infusion of 5-FU (1500 mg/m2 on day 1, 2), concurrently with LV (45 mg on day 1, 2) as a 2 hour infusion. Cycles were repeated by 2-week intervals. We compared the response rates according to clinical factors such as primary sites, cycle, tumor differentiation, metastatic sites, serum CEA, and previous chemotherapy.
RESULTS
Of the 44 patients who had received the combination chemotherapy with oxaliplatin, 5-FU, and LV, 19 cases were male, 25 cases were female. The median age was 50.7 years. The primary tumor sites were colon in 21 cases (47.7%), and rectum in 23 cases (52.3%). The metastatic sites were liver in 27 cases (61.4%), lung in 9 (20.5%), pelvis in 3, lymph node in 5, and peritoneum in 1. Thirty- five patients had received the combination chemotherapy as first line. Complete response was observed in 3 cases (6.8%). Partial response was in 7 cases (15.9%), stable disease status in 15 cases (34.1%), progressive disease status in 19 cases (43.2%), respectively. There were a no significant differences in response rates according to primary sites, tumor differentiation, serum CEA, and previous chemotherapy. However, with the metastatic sites, there were significant differences in response rates. Response rates were higher in lung (5/9), lymph node (3/4) metastases than any other metastatic sites (P <0.01).
CONCLUSIONS
The objective response rate of FOLFOX 3 was 22.7% in metastatic colorectal cancers. The only significant clinical factor was metastatic sites. The lung and lymph node metastases showed better response than metastatses to liver, pelvis, and peritoneum. To evaluate the differences of response rates according to metastatic sites, we need further study.

Case Reports

A Case of Hemorrhage from a Diverticulum of the Appendix.: Choi, Sung Il , Shin, Jong Keun , Lee, Sook Hee , Kim, Do Sun , Lee, Doo Han , Kang, Yun Sik; J Korean Soc Coloproctol. 2005;21(1):48-51.

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Abstract PDF: Diverticulum of the vermiform appendix is infrequently encountered, and in the absence of inflammation, it has been reported to be asymptomatic. Furthermore, hemorrhage from an appendiceal diverticulum is extremely rare, and has not yet reported in our country. We report a case of hemorrhage occurring in appendiceal diverticulum.

A Case of Non-Hodgkin's Lymphoma in Ulcerative Colitis.: Han, Kyong Rok , Yu, Chang Sik , Yang, Suk Kyun , Jeong, Young Hak , Park, In Ja , Lee, Kang Hong , Kim, Hee Cheol , Kim, Jin Cheon; J Korean Soc Coloproctol. 2005;21(1):52-56.

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Abstract PDF: Malignant intestinal lymphoma complicating ulcerative colitis has been reported. Although the association of colorectal cancer with ulcerative colitis is well described, the association of intestinal lymphoma, ulcerative colitis and prior immunosuppression remains unclear. However, it is important to be aware of the possible risk of lymphoma and carcinoma when patients shows unexpected signs of deterioration or when the clinical course of ulcerative colitis is atypical. Substantial biopsies with colonoscopy are required to make an unequivocal diagnosis in such patients. We report the case of non-Hodgkin's lymphoma in ulcerative colitis with review of the literature.

Review

Current Status of Stoma Researches in Korea.: Lee, Suk Hwan , Park, Eung Bum; J Korean Soc Coloproctol. 2005;21(1):57-63.

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Abstract PDF: Stoma operations are one of the most frequently performed operation by the colorectal surgeons. And the consequences of the stoma operation of the patients are well known. However, most colorectal surgeons who performed stoma operation were not aware of the problems that are part of the rehabilitation of the ostomates. In order to elucidate the current status of the stoma studies in Korea, literature reviews were performed by using the Korean medical literature database. Most of the Korean literatures written by the colorectal surgeons are related with the postoperative complications of stoma surgeries. Very few papers are concerned with rehabilitation issues including postoperative adaptation of ostomates, quality of life, and stoma nursing care. Recently, more and more papers concerning the stoma rehabilitation issues were published and the interests in the patient's adjustment to a change in body function are growing. Stoma rehabilitation program should be the part of the nations' welfare program which would be successful with the active participation of the colorectal surgeons, enterostomal therapists and ostomates. We, colorectal surgeons, and the Korean Society of Coloproctology should do the major role in stoma-related researches and cooperate with the enterostomal therapists and ostomates organizations in order to establish and develop the stoma rehabilitation program in Korea.

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